Inspection Reports for
Valley Manor and Rehabilitation Center
1410 HOSPITAL DR, EXCELSIOR SPRINGS, MO, 64024-1168
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
18% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
56% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 67
Deficiencies: 5
Date: Dec 18, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, hygiene, nutrition, food safety, and infection control at Valley Manor and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including incomplete and inaccurate resident care plans, failure to provide timely showers to dependent residents, failure to accommodate resident dietary preferences especially related to religious restrictions, poor food safety and sanitation practices in the kitchen, and inadequate infection prevention and control practices including improper use of personal protective equipment (PPE).
Deficiencies (5)
Failure to ensure resident care plans were created accurately and comprehensively for sampled residents, including failure to address wheelchair seatbelt use and specific care needs.
Failure to provide timely showers for dependent residents unable to carry out activities of daily living, resulting in inadequate personal hygiene.
Failure to honor a resident's religious dietary preferences by serving pork and failing to provide suitable substitutes.
Failure to maintain food service safety standards including improper handwashing, lack of hairnets, poor kitchen cleanliness, inadequate food storage and labeling, expired food items, and improper food presentation.
Failure to implement an effective infection prevention and control program, including failure to use PPE properly and lack of infection surveillance.
Report Facts
Facility census: 67
Resident showers documented: 10
Pork meals served: 29
Expired food items: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Named in infection control deficiency for failure to change gloves and wash hands appropriately |
| CNA A | Certified Nurse Aide | Named in infection control deficiency for failure to use gowns and change gloves properly |
| RN A | Registered Nurse | Interviewed regarding care plan compliance and shower frequency |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan compliance and shower frequency |
| Director of Nursing | DON | Interviewed regarding care plan compliance, shower frequency, and infection control expectations |
| Administrator | Interviewed regarding care plan compliance, shower scheduling, dietary preferences, kitchen oversight, and infection control | |
| Dietary Manager | DM | Interviewed regarding dietary preferences, kitchen sanitation, and food safety |
| Dietary Aide B | Dietary Aide | Interviewed regarding dishwasher sanitation practices |
| Dietary Aide C | Dietary Aide | Observed and interviewed regarding glove use and kitchen sanitation |
Inspection Report
Routine
Census: 63
Deficiencies: 1
Date: May 1, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with medication administration policies, specifically regarding pain management for residents.
Findings
The facility failed to administer prescribed pain medication (pregabalin) to one resident as ordered, resulting in unnecessary pain. Interviews and record reviews confirmed multiple missed doses during April 2025.
Deficiencies (1)
Failure to administer medications for pain management in accordance with the resident's physician orders, causing unnecessary pain for one resident.
Report Facts
Residents affected: 1
Facility census: 63
Missed medication doses: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding medication administration expectations | |
| ADON | Interviewed regarding unexplained gap in medication administration |
Inspection Report
Routine
Census: 68
Deficiencies: 11
Date: Jul 10, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care, safety, infection control, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights, inadequate care planning, delayed and inadequate response to call lights, poor hygiene and grooming care, failure to maintain a safe and clean environment, improper medication administration, inadequate infection control practices, failure to ensure proper nutrition and hydration, and deficiencies in food service safety and sanitation.
Deficiencies (11)
Failure to respect resident rights including timely response to call lights and preserving dignity.
Failure to develop and implement individualized, comprehensive care plans addressing ADLs, grooming, oral care, skin integrity, and psychosocial needs.
Failure to administer medications correctly including eye drops, nasal sprays, and Tylenol dosing errors.
Failure to provide adequate personal hygiene care including perineal care and showering as scheduled.
Failure to maintain a safe, clean, and homelike environment including unclean resident rooms, odors, damaged walls, and poor housekeeping.
Failure to ensure residents knew how to file grievances and failure to follow grievance procedures.
Failure to ensure adequate nutrition and hydration including failure to pass fluids regularly and serve palatable, appropriately prepared meals at proper temperatures.
Failure to ensure food service safety including improper food storage, expired foods, unclean kitchen and equipment, and inadequate cleaning and sanitizing of kitchen surfaces and equipment.
Failure to ensure safe resident transfers including improper use of mechanical lifts and failure to lock wheelchairs during transfers.
Failure to implement infection prevention and control program including failure to place residents on enhanced barrier precautions and improper catheter care.
Failure to implement an antibiotic stewardship program with monitoring and tracking of antibiotic use.
Report Facts
Facility census: 68
Shower frequency: 1
Expired medications: 3
Food temperature: 118.5
Food temperature: 117.6
Dishwasher sanitizer reading: 100
Food storage: 6
Food temperature: 183.5
Food temperature: 130.4
Food temperature: 134.4
Food temperature: 120.3
Food temperature: 130
Food temperature: 118.5
Food temperature: 131.9
Food temperature: 127
Food temperature: 145
Food temperature: 135
Food temperature: 41
Food temperature: 160
Food temperature: 165
Food temperature: 120
Food temperature: 183.5
Food temperature: 187.1
Food temperature: 179.4
Food temperature: 182.3
Food temperature: 167.1
Food temperature: 180.6
Food temperature: 170.9
Food temperature: 148.8
Food temperature: 152.6
Food temperature: 155.1
Food temperature: 130
Food temperature: 120.3
Food temperature: 131.9
Food temperature: 117.6
Food temperature: 130.4
Food temperature: 134.4
Food temperature: 120.3
Food temperature: 130
Food temperature: 118.5
Food temperature: 131.9
Food temperature: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in medication administration deficiencies including eye drops and nasal spray administration |
| CNA D | Certified Nurse Aide | Named in personal care and infection control deficiencies |
| CNA B | Certified Nurse Aide | Named in shower and shaving care deficiencies |
| Dietary Manager | Named in food service and kitchen sanitation deficiencies | |
| Dietary Aide B | Named in food preparation and sanitation deficiencies | |
| Administrator | Named in multiple interviews regarding facility expectations and deficiencies | |
| Director of Nursing | Named in multiple interviews regarding care planning, infection control, and medication administration | |
| NA D | Nurse Aide | Named in personal care and infection control deficiencies |
| CNA A | Certified Nurse Aide | Named in personal care deficiencies |
| CNA C | Certified Nurse Aide | Named in transfer and infection control deficiencies |
| Dietician | Named in food service and kitchen sanitation deficiencies | |
| NA A | Nurse Aide | Named in infection control deficiencies |
| CNA G | Certified Nurse Aide | Named in transfer deficiencies |
Inspection Report
Routine
Census: 68
Deficiencies: 2
Date: Jul 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident care, including activities of daily living assistance and food service quality.
Findings
The facility failed to ensure dependent residents received adequate assistance with activities of daily living such as perineal care, showers, and shaving. Additionally, the facility failed to serve food at safe and appetizing temperatures, with multiple residents reporting cold or burnt food.
Deficiencies (2)
Failure to provide complete perineal care, AM care, showers, and shaving to dependent residents.
Failure to serve food that was palatable, attractive, and at a safe and appetizing temperature, including serving burnt and cold food to residents.
Report Facts
Facility census: 68
Showers received: 5
Showers received: 3
Showers received: 5
Food temperature: 117.6
Food temperature: 118.5
Food temperature: 120.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aide | Named in findings related to inadequate perineal care and resident hygiene |
| CNA B | Certified Nurse Aide | Named in findings related to shaving and nail care deficiencies |
| Dietary Aide B | Dietary Aide | Named in findings related to food temperature monitoring and serving burnt food |
| Dietary Manager | Dietary Manager | Named in findings related to food temperature monitoring and food quality |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for resident care and hygiene |
| Administrator | Administrator | Interviewed regarding expectations for resident care and food service |
Inspection Report
Census: 60
Deficiencies: 5
Date: Feb 23, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, preferences for bathing and snacks, resident trust fund management, medication administration, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding assistance, failure to honor residents' bathing and snack preferences, failure to notify a resident or responsible party when trust fund balance exceeded SSI limits, medication administration errors including improper eye drop technique, and failure to maintain proper food labeling, dating, and sanitary food handling practices.
Deficiencies (5)
Staff failed to ensure residents were treated with dignity when assisting with eating by standing rather than sitting, affecting three residents.
Facility failed to honor residents' preferences for at least two showers per week and failed to provide bedtime snacks as ordered for several residents.
Facility failed to notify resident or responsible party when resident's trust fund balance exceeded Supplemental Security Income resource limit.
Medication administration errors occurred with a 14.29% error rate, including improper eye drop technique such as touching the dropper tip to the eye and inadequate lacrimal pressure application.
Food items were not properly labeled, dated, or sealed; food safety practices including handwashing and glove use were inadequate in the kitchen.
Report Facts
Medication errors: 4
Residents affected by dignity deficiency: 3
Residents affected by bathing/snack deficiency: 4
Resident trust fund balance: 6557.25
Facility census: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician A | Named in medication error finding related to improper eye drop administration. | |
| Certified Medication Technician C | Named in medication error finding related to improper eye drop administration. | |
| Certified Medication Technician D | Interviewed regarding medication administration and snack distribution. | |
| Nurse Aide A | Interviewed regarding feeding assistance and showering practices. | |
| Certified Nurse Aide B | Interviewed regarding shower assignments and snack distribution. | |
| CNA C | Interviewed regarding shower assignments. | |
| CNA D | Interviewed regarding shower assignments. | |
| Director of Nursing | Director of Nursing | Interviewed regarding feeding assistance, showering, snack provision, and medication administration policies. |
| Business Office Manager | Business Office Manager | Interviewed regarding resident trust fund management. |
| Dietary Manager | Dietary Manager | Interviewed regarding food labeling, dating, and handwashing practices. |
| Dish Aide A | Interviewed regarding food preparation and labeling practices. | |
| Cook B | Observed and interviewed regarding handwashing and trash handling practices. |
Inspection Report
Routine
Census: 61
Deficiencies: 2
Date: Jan 8, 2020
Visit Reason
The inspection was conducted to assess the safety, cleanliness, and comfort of the nursing home environment, specifically focusing on the presence of black substances and stained ceiling tiles in various areas of the facility.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment by not identifying and addressing black mold-like substances on restroom ceilings and stained ceiling tiles in multiple locations. Staff were unaware of these issues, and the Maintenance Supervisor and Administrator acknowledged the need for immediate correction and improved monitoring.
Deficiencies (2)
Failure to identify and address black substance (mold-like) on restroom ceilings.
Failure to address stained ceiling tiles in multiple areas including corridors and dining room.
Report Facts
Facility census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Unaware of black mold-like substance on restroom ceilings until discovered during inspection | |
| Maintenance Supervisor | Supervisor (MS) | Acknowledged stained ceiling tiles and mold-like substance, noted lack of monitoring |
| Administrator | Administrator | Stated staff should monitor ceilings and address black substance immediately |
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